Developing a core competency framework for community-based psychiatric rehabilitation practitioners in China: a modified Delphi study

Abstract

Background

Competency-based training is essential for building a qualified workforce in community-based psychiatric rehabilitation. Yet China lacks a contextually grounded competency framework to guide training, assessment, and service quality. This paper aims to develop a core competency framework tailored to community-based psychiatric rehabilitation practitioners in China.

Methods

We used a structured three-phase process: (1) a rapid literature review and conceptualization; (2) framework drafting; and (3) a two-round Delphi survey with 29 multidisciplinary Chinese experts to refine and achieve consensus on indicators. Expert engagement and consensus were assessed using standard metrics.

Results

Eleven relevant international competency frameworks were reviewed to inform the initial drafting of the indicators. Following internal consultation and two rounds of Delphi survey, the coefficients of variation for the importance ratings of the indicators ranged from 0.00 to 0.23 (Round 1) and 0.00 to 0.20 (Round 2), indicating strong consensus among the experts. The final framework consists of 55 secondary indicators organized under 6 primary indicators: attitudes, beliefs, and values; ethical principles; professionalism; learning and development; basic knowledge; and basic skills - forming the acronym AEPLKS (pronounced “apex”).

Conclusions

The framework not only aligns with international standards for person-centered, recovery-oriented, and ethical practice but is also culturally adapted to the Chinese context. Given workforce shortages and the absence of similar frameworks in many low- and middle-income countries, it may serve as a reference for developing contextually appropriate community-based psychiatric rehabilitation competency frameworks in other settings. Nonetheless, given that the AEPLKS framework is a preliminary, expert-derived one, further empirical validation will be required before its application in certification or formal performance assessment.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12888-026-08352-y.

Background

Rehabilitation in the health context is a multifaceted process aimed at optimizing functioning and reducing disability in individuals with health conditions. As defined by the World Health Organization (WHO) [1], rehabilitation involves “a set of interventions designed to optimize functioning and reduce disability in individuals with health conditions in interaction with their environment”. Within this broad framework, community-based psychiatric rehabilitation (CBPR) represents a specific form of rehabilitation designed to address the multifaceted needs of individuals with mental illness. By integrating biological, social, and environmental dimensions, CBPR uniquely facilitates sustained recovery and enhances quality of life for this population [2, 3]. Studies have consistently demonstrated the benefits of CBPR for individuals with mental illness, including enhanced social functioning [4], decreased use of psychotropic medication [5], greater long-term well-being [6], and improved quality of life [7].

However, the shortage of human resources, particularly in low- and middle-income countries (LMICs), remains a major barrier to the implementation of CBPR services. Many LMICs lack adequately trained professionals to deliver CBPR services, thereby constraining their availability and quality [8]. China illustrates both progress and gaps in this regard. In 2019, it had 3.7 psychiatrists and 8.7 registered psychiatric nurses per 1 million people - figures above the global average but far below those in Europe [9]. This shortage is further exacerbated by inadequate funding, limited infrastructure, enduring stigma [10], and insufficient staff training and continuing education [11] in CBPR services, leaving many individuals in LMICs deprived of essential CBPR services and subject to worsening disability and social exclusion [12].

Competencies, defined as abilities to meet complex demands by mobilizing psychosocial resources, including skills and attitudes, within specific contexts - serve as a cornerstone for training mental health workforce [13]. These generalized descriptions of job-related abilities provide a structured framework to articulate the knowledge, skills, and attitudes essential for effective role performance. By delineating these elements, competencies fulfill three critical functions including curriculum development, professional growth, and service standards. Implementing robust competency frameworks is thus critical to strengthening mental health systems and achieving equitable access to care globally. In order to address the aforementioned human resource gap in CBPR services, it is of great significance to build an effective competency framework for CBPR training.

Internationally, organizations such as the WHO and the Psychiatric Rehabilitation Association (PRA) in the US have pioneered structured competency frameworks to guide CBPR practices. The WHO emphasizes five core domains for general-purpose rehabilitation practices, that is practice, professionalism, learning and development, management and leadership, and research, centered on several core values and beliefs [14], while the PRA’s competency framework, which is more specifically designed for psychiatric rehabilitation practices, outlines seven domains of core competencies that psychiatric rehabilitation practitioners should exhibit [15]. Similarly, the UK’s Royal College of Psychiatrists (RCPsych) prioritizes professional values and team leadership [16], and the Psychosocial Rehabilitation/Réadaptation Psychosociale (PSR/RPS) Canada integrates diversity, inclusion, and trauma-informed practices [17]. Academic institutions like Boston University and the University of California, Los Angeles (UCLA) further reinforce these principles through curricula development focused on rehabilitation diagnosis and multidisciplinary collaboration [18, 19]. However, although some competency frameworks for psychiatric rehabilitation exist in high-income countries, they are primarily designed for general psychiatric rehabilitation contexts rather than for the specific context of CBPR practice. Moreover, these frameworks are largely grounded in Western cultural perspectives that emphasize individualism, autonomy, and self-determination. Such value orientations may not fully align with the collectivist cultural contexts of many LMICs, where family involvement and relational interdependence often play a more central role in service delivery. As a result, the direct transferability and contextual applicability of these existing frameworks to LMIC settings remain limited and warrant careful adaptation.

China has placed significant emphasis on CBPR as a critical component of mental health care reform, integrating it into the 2013 Mental Health Law and setting ambitious targets in the 2017 “Opinions on Accelerating the Development of Community-based Psychiatric Rehabilitation”, that is, by 2025, over 80% of cities are expected to provide CBPR services, reaching 60% of home-based individuals with mental illness. Further guidelines, such as the 2020 “Standards for Community-based Psychiatric Rehabilitation Services” and the 2021 three-year “Psychiatric Rehabilitation Integration Action” plan, aim to establish a structured CBPR service system in China [20]. So far, CBPR services in China are primarily delivered through social work organizations, which play a pivotal role in bridging the gap between hospital-based mental health care services and community living and inclusion needs of people with mental illness [20]. However, human resources remained limited for these social work organizations. By 2015, mental health social workers in China numbered 1500, taking up only 1.2% of the overall mental health workforce [21]. Furtherly, social workers in these organizations often lack specialized training in CBPR, leaving them ill-equipped to provide effective and evidence-based rehabilitation services.

International CBPR competency frameworks, though valuable, are largely built on Western mental health paradigms and service delivery models, and thus only partially fit the Chinese context. China’s mental health system and culturally shaped understandings of mental illness differ from those elsewhere, influencing service expectations, family roles, and care pathways [22]. As a result, existing frameworks seldom address China-specific cultural norms, social structures, family dynamics, and service models used locally. Many international frameworks assume mature medical and community infrastructures and robust multi-sector coordination. However, in many regions of China, health resources and specialist staff are scarce, follow-up support is limited, and service chains are incomplete, making direct transplantation of international frameworks impractical. Differences in governance and case-management arrangements further impede translating the existing frameworks into routine practice in China. A localized framework aligned with China’s mental health system, culture, and resource realities is therefore needed.

In order to address the gap, this study aims to develop a core competency framework for CBPR practitioners in China which can serve as an essential tool to assess staff performance, inform training curricula, standardize certification procedures, and align CBPR services with China’s socio-cultural realities. Importantly, the framework is intended for CBPR practitioners across professional backgrounds, rather than being limited to any single discipline. It is therefore conceptualized as a cross-professional framework applicable to practitioners from diverse disciplines involved in CBPR service delivery, including but not limited to social work, psychiatry, public health, nursing, and other related health and social care professions. Such positioning reflects the inherently interdisciplinary nature of CBPR practice in China. A tailored competency framework of this kind must balance foundational competencies, such as ethics and cultural sensitivity, with specialized practice skills, while also integrating relevant global best practices [23].

Methods

This study aimed to develop a core framework for CBPR practitioners in China and comprises three phases. In the first phase, a literature review and conceptualization were conducted to identify the indicators of CBPR practitioners. In the second phase, indicators were compiled and refined by the research team to prepare the draft of the core competency framework for CBPR practitioners. In the third phase, the Delphi method with 29 experts was used to refine and achieve consensus on the framework.

Phase 1: Literature review and conceptualization

A rapid literature review and conceptualization were conducted before developing the preliminary draft. Both peer-reviewed articles and grey documents that discuss the competency framework of CBPR practitioners were included. First, a comprehensive search strategy was performed in the PubMed and Web of Science (WOS) databases. The search terms were developed around three key concepts: mental illness, rehabilitation, and competency, with relevant keywords and synonyms incorporated for each concept. The full search strategies were shown in Appendix 1. Second, a manual search of grey literature on the competency framework of CBPR practitioners in Organization for Economic Co-operation and Development (OECD) countries was conducted, as existing studies indicated that there were few competency frameworks in LMICs [24]. We identified sources including professional associations, government agencies, academic institutions, institutional repositories, conferences and workshops, and non-governmental organizations (NGOs).

Literature was included if it described one or more frameworks of the core competencies, such as attitudes, knowledge, and skills, required for psychiatric rehabilitation practitioners, including both specialist and non-specialist personnel. The frameworks should be designed for the use in psychiatric rehabilitation settings. Therefore, although some frameworks, such as the WHO mhGAP toolkit, include basic knowledge and skills related to the identification, assessment, and clinical management of mental disorders which are also essential for psychiatric rehabilitation, they were excluded if they did not explicitly address competencies required for rehabilitation practitioners. Literature published in non-English languages or without available full texts was also excluded. The flowchart for the rapid literature review was present in Appendix 2.

The data extraction form captured three main categories of information: (1) characteristics of the included literature, including authors and year of publication; (2) characteristics of the competency framework described in the literature, including framework name, country of application, year of development, and target population; and (3) competency domains and indicators of the framework, including their names, definitions, and detailed descriptions. This structured approach allowed for systematic comparison of competency frameworks across different contexts.

Phase 2: Drafting

Drawing upon our own experience in CBPR research and practice, the research team developed a preliminary core competency framework for Chinese CBPR practitioners based on the findings of the literature review. First, the competency indicators identified from the literature review were compiled and screened according to their relevance to psychiatric rehabilitation practice in community settings and their applicability to the Chinese context. Indicators with substantial semantic overlap or conceptual redundancy were consolidated to reduce duplication. In addition, several contextually important concepts, such as familism, were incorporated to ensure that the framework adequately reflected the characteristics of China’s CBPR service delivery system and broader sociocultural environment. Since it is not uncommon that CBPR practitioners in China have diverse educational backgrounds, particular attention was paid to the wording of competency indicators. The language used in the framework was carefully reviewed and, where necessary, revised to enhance clarity, accessibility, and ease of understanding while maintaining conceptual accuracy.

Following the development of the preliminary framework, an internal consultation process was undertaken with an advisory board comprising nine highly experienced CBPR experts. The purpose of this process was to critically review the framework and further refine its content, structure, and wording. Advisory board members were invited through the research team’s professional networks using a purposive sampling approach and were selected based on their expertise in CBPR. All advisory board members had more than ten years of professional experience and represented diverse disciplinary backgrounds, including mental health social work (n = 4), clinical psychiatry (n = 3), public mental health (n = 1), and mental health education (n = 1). Two rounds of internal consultation meetings were conducted. Through in-depth discussions and consensus-building, the competency domains and indicators underwent iterative revision to enhance their relevance, coherence, conciseness, and clarity. The resulting framework served as the draft version for the subsequent Delphi survey.

Phase 3: Delphi process

Expert participants

A purposive sample of external consulting experts was invited to participate in the subsequent Delphi survey. The inclusion criteria for consulting experts were as follows: (1) having at least five years of experience in first-hand provision or management of CBPR services in China, or at least five years of experience in research on CBPR services in China; (2) holding a bachelor’s degree or higher; (3) having a professional title of intermediate level or above according to the official classification standards for professional titles in China. Efforts were made to ensure diversity of these experts in terms of geographical distribution, institution type, and professional background.

Data collection

Two rounds of Delphi survey were conducted from October to December 2024 via E-mail. The questionnaire on the core competencies of CBPR practitioners in China was designed based on the refined draft produced in the previous phase and distributed to consulting experts. There were three sections contained in the questionnaire: (1) an expert consultation form, which included a 5-point Likert scale to assess the importance of each indicator (ranging from 1 = very unimportant to 5 = very important), as well as a comment box for experts to provide any revision suggestions for each indicator; (2) a socio-demographic information form for experts, and (3) a familiarity and judgement basis form for expert. In the second-round questionnaire, the results of the first-round survey were also provided to experts for reference.

During the Delphi process, external consulting experts were required to evaluate the importance of each indicator and to report their familiarity with the content as well as their judgement basis. After each round, all responses were collated and analyzed by the research team, including quantitative ratings and qualitative revision suggestions for each indicator. The research team systematically synthesized the feedback and revised the competency framework accordingly. In both survey rounds, indicators were retained if they met the predefined consensus criteria: a mean importance score of ≥ 4.5, a level of consistency of ≥ 90%, and a coefficient of variation (CV) ≤ 0.25.

In addition to these quantitative criteria, all qualitative comments and proposed revisions were carefully reviewed. Disagreements among expert opinions were not resolved by individual decisions. Instead, they were collectively discussed within the research team through structured meetings. Where divergent suggestions were identified, the team compared alternative viewpoints, examined their alignment with the conceptual framework, and reached consensus through discussion. Importantly, qualitative expert feedback also contributed to the refinement of the framework beyond revision of existing indicators. Several new indicators were added based on expert suggestions, including “dialect comprehension and usage” and “service documentation and report writing” during Round 1. All proposed modifications and additions were explicitly reviewed and approved by the research team prior to implementation in the subsequent Delphi round. Each change was documented with a clear rationale to ensure transparency and traceability of decision-making. Following two rounds of Delphi surveys, a high level of expert consensus was achieved across indicators.

Data analysis

SPSS version 27.0 was used for data analysis. Descriptive statistics were conducted, including means, standard deviations, and proportions. Expert participation was measured by the response rate. Expert authority was evaluated using the authority coefficient (Cr), calculated as Cr = (Cs + Ca) / 2, where the familiarity coefficient (Cs) represented the expert’s self-rate familiarity with the core competencies for CBPR practitioners in China, and the judgement coefficient (Ca) was the self-reported of the basis for their judgment. The degree of consensus was evaluated using Kendall’s W coefficient and the CV. A higher Kendall’s W indicates a higher degree of consensus among experts. The analytic hierarchy process was used to calculate the weights of the primary indicators retained in the final version of the competency framework.

Ethical considerations

This study involved a Delphi consensus process with expert participants. Ethical review and approval were waived by the Ethics Committee of Shanghai Mental Health Center, Shanghai Jiao Tong University, as the study was considered minimal risk. Specifically, the study involved anonymous surveys of expert opinion, with no intervention, no collection of sensitive personal or health-related data, and no foreseeable risk to participants. Participation in the Delphi survey was voluntary. All participants were provided with information about the survey and gave informed consent prior to participation. The anonymity and confidentiality of participants were maintained throughout the study. The study was conducted in accordance with the principles of the Declaration of Helsinki.

Results

Phase 1: Literature review and conceptualization

A total of 11 existing competency frameworks relevant with CBPR (Appendix 3) were reviewed as references for drafting the framework in this study. Although the WHO did not have a specific competency framework for psychiatric rehabilitation, its Rehabilitation Competency Framework (RCF) was included in our review because of its general applicability and relevance to rehabilitation practice [14]. Other identified competency frameworks included the national competency framework in US [15], Canada [17] and UK [16]. Additionally, we also reviewed the skills articulated in the psychiatric rehabilitation curricula [18, 19, 25–27], the expected areas of expertise for a multidisciplinary psychiatric rehabilitation team [23], and the training needs of rehabilitation and community mental health workers in six Western states of the US [28].

Phase 2: Drafting

Based on the result of the literature review and internal consultation with the advisory board of this study, a draft of the core competency framework for CBPR practitioners in China was developed. This framework contained seven primary indicators (attitudes, beliefs, and values; ethical principles; professionalism; learning and development; collaboration and coordination; basic knowledge; and basic skills), totalling 59 secondary indicators.

Phase 3: Delphi process

Socio-demographic information of the experts

A total of 29 external experts were consulted in the Delphi process. Table 1 shows their socio-demographic information. The average age of the experts was 43.65 ± 7.16 years. Among them, 15 were female and 14 were male. Regarding education background, 7 experts held doctoral degrees, 11 held master’s degrees, and another 11 held bachelor’s degrees. The experts represented a diverse range of professional backgrounds, including 13 experts specializing in social work, 7 in psychiatry, 4 in public health, 2 in nursing, 2 in psychology, and 1 in pedagogy. Additionally, 6 experts had a multidisciplinary training background. These experts were affiliated with a variety of institutions across the country, including psychiatric hospitals, social service agencies, and universities or colleges, with their primary field of research or practice focused on CBPR.

Table 1.

Socio-demographic characteristics of the experts (n = 29) that participated in the Delphi process

Characteristics	n (%) or Mean ± SD
Age (years), mean ± SD	43.65 ± 7.16
Gender
Male	14 (48.3)
Female	15 (51.7)
Education, N (%)
Bachelor’s degree	11 (37.9)
Master’s degree	11 (37.9)
Doctor’s degree	7 (24.2)
Professional background, N (%)
Social work	13 (44.8)
Psychiatry	7 (24.2)
Public health	4 (13.8)
Nursing	2 (6.9)
Psychology	2 (6.9)
Pedagogy	1 (3.4)
Professional title, N (%)
Senior level	15 (51.7)
Intermediate level	14 (48.3)
Professional experience (years), mean ± SD	20.24 ± 8.69
Institution type, N (%)
Psychiatric hospital	12 (41.4)
University or college	8 (27.6)
Social service agency	7 (24.2)
Center for disease control and prevention	1 (3.4)
Government agency	1 (3.4)

Participation and feedback of the experts

In the first round, all 29 experts agreed to participate in the survey and returned the questionnaire, achieving a response rate of 100%. However, in the second round, one expert was unable to participate given time limitations, resulting in a response rate of 96.6%. Expert engagement remained consistently high throughout the Delphi process. A total of 42 revision suggestions were collected in the first round and 15 in the second round, amounting to 57 pieces of expert feedback across both rounds.

Authority of the experts

In the first round, the Cs was 0.87, and the Ca was 0.94, resulting in an overall Cr of 0.90. In the second round, the Cs was 0.84, and the Ca was 0.92, yielding a Cr of 0.88. Given that a Cr of 0.70 or higher is generally considered acceptable, both rounds of survey demonstrate a high level of expert authority.

Coordination and consensus among the experts

During the first round of survey, the coefficients of variation (CV) for the importance ratings of the indicators included in the draft competency framework ranged from 0.00 to 0.23, and the Kendall’s W coefficients for the primary and secondary indicators were 0.137 and 0.153, respectively (both P < 0.001). In the second round, the CVs for the indicators retained after the first-round survey ranged from 0.00 to 0.20 and the Kendall’s W coefficients ranged from 0.147 to 0.235 (both P < 0.001), indicating good coordination among the experts (Table 2).

Table 2.

Coefficients of variation and Kendall’s W coefficients in both rounds of Delphi survey

	Coefficients of variation (CV)	Kendall’s W	P
First-round survey
Primary indicators	0.04 to 0.16	0.137	< 0.001
Secondary indicators	0.00 to 0.23	0.153	< 0.001
Second-round survey
Primary indicators	0.04 to 0.15	0.235	< 0.001
Secondary indicators	0.00 to 0.20	0.147	< 0.001

Refinement and finalization of the competency framework

After the first-round survey, several revisions were made to the primary and secondary indicators in the competency framework based on the ratings and suggestions collected from the 29 experts. The primary indicator “collaboration and coordination” was removed, and its associated secondary indicators were merged into other two primary indicators “basic knowledge” and “basic skills”. In addition, several indicators were revised to improve their clarity, relevance, and applicability within the Chinese context of CBPR practice. Based on qualitative feedback, indicators such as “dialect comprehension and usage” and “service documentation and report writing” have been added. During the second-round survey, consensus was reached on the six primary indicators retained after the first round, and 15 out of the 55 secondary indicators were further refined. The final version of the core competency framework for CBPR practitioners in China is shown in Fig. 1; Table 3 (also see Appendix 4 for the Chinese version). The weight of each primary indicator is presented in Fig. 2.

Fig. 1.

Six primary indicators of the core competency framework for community-based psychiatric rehabilitation practitioners in China

Table 3.

Final version of the core competency framework for community-based psychiatric rehabilitation practitioners in China

Primary indicator	Secondary indicator	Definition
1. Attitudes, Beliefs, and Values	1.1 Respect	Show respect, acceptance, and care towards clients and their families.
	1.2 Non-Judgmental	Refrain from making value judgments about the thoughts, behaviors, and positions of clients and their families.
	1.3 Non-Discriminatory	Maintain an unbiased and non-discriminatory attitude towards clients and their families.
	1.4 Sincerity	Approach clients and their families with openness, honesty, and authenticity.
	1.5 Empathy	Understand and empathize with the experiences, thoughts, emotions, and behaviors of clients and their families.
	1.6 Optimism	Believe in the potential of clients and their families to achieve growth and improvement.
	1.7 Holistic Perspective	View clients as whole individuals and actively address their holistic needs.
	1.8 Individualization	Recognize and value the unique needs and feelings of each client as a distinct individual.
	1.9 Normalization	Avoid viewing clients from a pathological perspective.
	1.10 Client- and Family-Centered Approach	Be oriented toward the needs and goals of clients and their families, and engage in full consultation with them throughout the service process.
2. Ethical Principles	2.1 Confidentiality	Respect and protect the privacy of clients and their families, while understanding the exceptions to confidentiality and following the corresponding procedures for such exceptions.
	2.2 Self-Determination	Respect and promote the ability of clients and their families to make their own choices and decisions.
	2.3 Fairness	Ensure that clients and their families have equitable opportunities to access the resources and services they need.
	2.4 Informed Consent	Ensure that clients voluntarily consent to receive services after being fully informed about the service content, risks, benefits, and other relevant circumstances.
	2.5 Sanctity of Life	Strive to safeguard life and emphasize respect and cherishing of life in all situations.
	2.6 Minimizing Harm	Make every effort to avoid causing harm to clients and their families during the service process.
	2.7 Professional Boundaries	Establish and maintain professional boundaries with clients and their families, team members, and other stakeholders.
3. Professionalism	3.1 Passion	Sustain a passion for community-based psychiatric rehabilitation services.
	3.2 Diligence and Responsibility	Fulfill professional responsibilities to clients and their families, team members, and other stakeholders.
	3.3 Honesty and Integrity	Ensure honesty and integrity in practice, maintaining authenticity in services, records, reporting, and publicity.
	3.4 Standardized Services	Provide services to clients and their families in accordance with relevant government and institutional standards.
	3.5 Act Within Capacity	Provide services to clients and their families within one’s professional capacity and service scope, seeking support or making referrals when necessary.
	3.6 Convey Confidence	Instill confidence and hope in clients and their families, affirming their efforts and offering encouragement.
	3.7 Emotional Management	Possess strong emotional regulation skills, providing services to clients and their families with a stable and positive emotional state.
	3.8 Self-Compassion	Pay attention to, promote, and maintain one’s own physical and mental health and well-being while providing services.
	3.9 Evidence-Based Practice	Understand the basic principles and requirements of evidence-based practice and know how to apply them appropriately.
	3.10 Cultural Competence	Understand the differences arising from the backgrounds, such as regional, ethnic, cultural, socioeconomic, and gender backgrounds, of clients and their families, and recognize the differences between one’s own background and that of clients and their families.
	3.11 Flexibility and Innovation	Flexibly adjust service content and methods according to different situations and conditions, and seek innovation in services.
4. Learning and Improvement	4.1 Self-Reflection	Continuously reflect on one’s own attitudes, values, and practices, and make timely improvements.
	4.2 Knowledge Update	Proactively learn and apply knowledge and skills related to community-based psychiatric rehabilitation.
	4.3 Experiential Learning	Actively learn from and draw on the professional experiences of others in the field of community-based psychiatric rehabilitation.
	4.4 Peer Communication	Summarize one’s own experiences, engage in discussions with peers, and consider their suggestions.
	4.5 Professional Supervision	Receive supervision from experts or seasoned practitioners in the field of community-based psychiatric rehabilitation.
5. Basic Knowledge	5.1 Legal Norms	Be familiar with laws, regulations, rules, and other normative standards related to community-based psychiatric rehabilitation.
	5.2 Welfare Benefits	Be familiar with welfare benefits related to community-based psychiatric rehabilitation.
	5.3 Psychiatry	Be familiar with basic knowledge of psychiatry.
	5.4 Social Work	Be familiar with basic knowledge of social work.
	5.5 Psychological Interventions	Be familiar with basic knowledge of psychological interventions.
	5.6 Community Rehabilitation	Be familiar with basic knowledge of community rehabilitation.
	5.7 Health Education and Advocacy	Be familiar with basic knowledge of health education and advocacy.
6. Basic Skills	6.1 Dialect Comprehension and Usage	Possess the ability to understand and use dialects that match the service requirements.
	6.2 Engagement and Communication	Engage and communicate effectively with clients and their families.
	6.3 Relationship Building	Establish a mutually trusting professional relationship with clients and their families.
	6.4 Decision Support	Support clients and their families in making decisions after fully informing them of relevant information.
	6.5 Motivation Enhancement	Enhance the motivation of clients and their families to participate in rehabilitation services.
	6.6 Rehabilitation Assessment	Conduct assessments at different stages of service regarding the challenges, needs, strengths, risks, and progress of clients and their families.
	6.7 Rehabilitation Planning	Develop, implement, and regularly adjust rehabilitation plans in collaboration with clients and their families, based on assessment results.
	6.8 Rehabilitation Interventions	Master at least one or two evidence-based rehabilitation interventions suitable for local use.
	6.9 Ethical Decision-Making	Make decisions that adhere to ethical principles through analysis, assessment, and selection when facing ethical dilemmas.
	6.10 Risk Identification and Emergency Response	Timely identify various risks to clients and reasonably handle their emergency situations according to procedures.
	6.11 Multi-Stakeholder Cooperation and Coordination	Establish and maintain effective cooperation and communication with clients, their families, team members, and other stakeholders, and coordinate these efforts.
	6.12 Resource Integration and Linkage	Understand, discover, mobilize, and integrate various community and social resources, and link these resources to clients and their families.
	6.13 Environmental Improvement	Improve various aspects of the client’s environments (e.g., family, community) to facilitate their recovery.
	6.14 Service Referral and Termination	Master the basic procedures and practices of service referral and termination.
	6.15 Service Documentation and Report Writing	Master the basic skills of report writing and properly document services as required.

Fig. 2.

Indicator weights of the core competency framework for community-based psychiatric rehabilitation practitioners in China

Discussion

Competency-based training is essential for cultivating CBPR practitioners with sufficient competencies and maintaining the quality of CBPR services. Developing a core competency framework for CBPR practitioners serves as a critical foundation for advancing competency-based training efforts [29]. Our study contributes by constructing a core competency framework specifically designed for CBPR workers in China, using a structured three-phase process that included a rapid literature review and conceptualization, framework drafting, and a Delphi survey. Importantly, rather than offering a universally applicable model, it is designed as a contextually grounded framework that reflects the cultural, relational, and institutional conditions of the Chinese setting. As such, it encourages careful adaptation when applied in other contexts, with attention to local sociocultural and system-level differences.

The final framework comprises 55 secondary indicators organized under 6 primary indicators: attitudes, beliefs, and values; ethical principles; professionalism; learning and development; basic knowledge; and basic skills - forming the acronym AEPLKS (pronounced “apex”). This framework will guide the design and delivery of future training and could also provide certification and performance evaluation for CBPR practitioners in China. Given the widespread shortage of CBPR practitioners and the absence of relevant competency frameworks standards in many LMICs, it may serve as a valuable reference to develop context-specific CBPR frameworks elsewhere.

Developed by reviewing and synthesizing comparable international frameworks, our model aligns closely with global standards, such as those articulated by the WHO [30], and defines the core competencies expected of community-based mental health providers. It includes widely recognized elements such as cultural sensitivity, effective communication, interdisciplinary teamwork, and ethical decision-making as reflected in the frameworks from the UK and Canada [16, 17]. This alignment underscores a shared global commitment to person-centered care, recovery-oriented practice, and ethical professionalism [31, 32]. By situating our framework within this international context, we ensure its relevance and adaptability to diverse community mental health settings. Although informed by international models, we localized the framework by selecting and adapting indicators and conducting a Delphi survey with 29 Chinese CBPR experts, ensuring cultural fit for the Chinese context.

Localization of social work in the Chinese context

Although the framework is designed as transdisciplinary, it is largely grounded in social work philosophy and practice, reflecting the reality that most CBPR practitioners in China are community-based social workers [20]. Core principles such as normalization, holism, and person-centeredness therefore shape the framework’s conceptual foundation.

While introduced from the West, social work in China has undergone significant localization [33]. For example, social work in the US is rooted in individualism, self-determination, and democratic principles, whereas, in China, it is shaped by the traditional Confucian values, which prioritize family-centeredness, respect for authority, and maintenance of social harmony [34]. Consequently, the practice of CBPR in China must go beyond simply importing Western concepts such as individual autonomy, self-determination, and self-direction; it requires significant localization of these concepts to address the central role of the family and relational perspective in maintaining harmony in decision-making, community networks, and collective well-being [34]. This localization strengthens cultural relevance, effectiveness, and legitimacy.

Family-oriented relational society

In Chinese society, family members frequently serve as surrogate decision-makers and primary coordinators of care, often organising treatment, monitoring adherence, and liaising with health professionals [35]. Family support is crucial for recovery and community reintegration [36], yet families face substantial challenges, including pressures toward involuntary hospitalisation and social isolation of individuals with mental illness, driven by concerns about reputation and family harmony [37]. Recognising these realities, our framework places families at the centre of care planning and delivery, including the role of families in almost all six primary indicators. This approach reflects cultural norms and the practical need for family-led, long-term rehabilitation in the context of scarce community mental health services in China [20]. In doing so, the framework aims to ensure that interventions are culturally responsive and effective within the Chinese sociocultural context.

Plus, CBPR practice in China operates within a “familiar-person” culture shaped by guanxi, where personal and professional relationships often overlap [38]. Providers and service users may share social networks or community ties, which can facilitate trust and communication. As Zhao observes, China’s ethics‑based “differential mode of association” produces a layered model that blends fixed ties, formal professional roles, and friendship, rather than a strictly Western professional form of social work. Familiarity can build trust and ease communication, but it also blurs boundaries and threatens objectivity, inviting role confusion, boundary crossings, and over‑involvement, and heightening burnout and compassion fatigue [39]. Expectations to exceed formal duties as relational obligations further deplete emotional resources. Chinese CBPR practitioners therefore require strong ethical judgement, self‑awareness, and relational management to balance trust with professional boundaries in such “familiar‑person culture”, reflected in Secondary Indicator 2.7 “professional boundaries”.

Peer support and informal professional development

Given limited access to expert supervision and formal professional support, particularly in rural and community settings, Chinese CBPR practitioners often rely on peer learning and informal mentorship [40]. These peer networks provide practical guidance and emotional support, and are vital resources for self‑care, resilience, and mutual coping under challenging conditions. Building competencies in collaborative practice and peer mentoring (such as Secondary Indicator 4.4 “peer communication”) is therefore critical to sustaining practitioners’ wellbeing and preventing professional exhaustion in the Chinese context.

Multi-sectoral governance and institutional navigation

Our framework also recognises the administrative landscape of community mental health services in China, which spans three major government sectors: health, civil affair, and public security [41]. Each plays a distinct role—health authorities focus on clinical care and rehabilitation; civil affair authorities oversee community supports and social welfare; and public security authorities manage cases involving public‑order risks or legal issues. This multi‑sectoral arrangement requires CBPR practitioners in China to navigate complex institutional boundaries and work effectively with professionals from diverse bureaucratic backgrounds. Competencies in interdepartmental coordination are therefore essential to ensure continuity of care and integrated service delivery. In addition, the highly regulated nature of China’s mental health system demands strong skills in documentation, report writing, and compliance—competencies that are less emphasised in systems with more decentralised or less bureaucratic structures. These skills are necessary not only to meet legal and policy requirements, but also to advocate for service users within a complex and sometimes fragmented system, informed by the Secondary Indicators such as 6.11 “multi-stakeholder cooperation and coordination”, 6.14 “service referral and termination”, and 6.15 “service documentation and report writing”.

Under national programmes such as the “686 Programme,” strong emphasis is placed on managing risks associated with severe mental illness [42, 43]. CBPR practitioners are therefore expected to balance recovery-oriented care with responsibilities for public safety. This creates an inherent tension between empowerment-oriented values and risk-control mandates. To address this, the framework includes competencies in risk identification and emergency response, reflected in Secondary Indicator 6.10 “risk identification and emergency response”, requiring proficiency in assessing potential threats, responding promptly to crises, and coordinating effectively with government departments during such events.

Negotiating evidence-based practice in the Chinese context

During the Delphi process, experts debated whether specific indicators should be included in the final framework. One of the most contested was “evidence‑based practice” (EBP). Experts with medical backgrounds generally endorsed EBP, whereas many social work experts were more sceptical, despite EBP’s prominence in international social work [44]. One explanation lies in the disciplinary history of contemporary Chinese social work, which since the 1980s has been rebuilt largely by scholars trained in sociology—a field in China with strong post‑positivist, social constructionist, and interpretivist orientations. As a result, many experts question the positivist underpinnings of EBP and emphasise local context and heterogeneity. To reconcile these views, our framework stresses both an understanding of the core principles of EBP and their judicious application—eschewing wholesale transplantation of evidence‑based interventions in favour of adaptation for cultural and contextual relevance, exhibited by Secondary Indicator 3.9 “evidence-based practice”.

Implementation challenges and limitations

Although the framework developed in this study offers guidelines for standardising the education, training, and professional development of CBPR practitioners in China, several challenges remain for implementation. First, because CBPR training in China is still in its early stages, the conditions for objective assessment of competencies, for instance, standardised client simulations, are lacking [45]. Self‑assessment may therefore be the most practical—if imperfect—approach in the near term, although it is susceptible to social desirability bias and overestimation of competence [46]. Second, given the breadth of CBPR’s foundational knowledge and skills, further research is needed to develop tertiary indicators beneath the secondary categories of “basic knowledge” and “basic skills”. Third, as CBPR remains an emerging field in China, expert consensus on role boundaries is limited, and the framework has not yet been tested in real‑world settings. Its applicability, feasibility, and impact on service delivery therefore remain to be established. Future studies should synthesise existing evidence on CBPR practitioners’ scope of practice and clarify professional boundaries within China’s mental health system.

This study has several limitations. First, we conducted two Delphi rounds with 29 experts, who were predominantly based in urban areas and drawn mainly from specific professional backgrounds, particularly social work. This may have limited the representation of rural perspectives, ethnic minority contexts, and other professional viewpoints. Nonetheless, given the relatively small pool of CBPR experts in China, we endeavored to include as diverse a sample as possible across disciplines and geographic regions. Second, to maintain concision and usability, several indicators—particularly those related to basic knowledge and skills—were not elaborated in detail, which may hinder implementation. Future work should specify these indicators according to local contexts. Third, the lack of service user or caregiver involvement in the framework development process represents a significant limitation, which may have resulted in the omission of domains considered important from service users’ or caregivers’ perspectives. Further research should therefore more substantially incorporate the experiential knowledge of service users and caregivers to further refine the framework. Finally, although the framework was developed through a structured Delphi process, expert ratings may still be subject to social desirability bias. Future research should focus on empirical validation across diverse real‑world settings before its application in certification or formal performance assessment. Such studies are essential to further refine the framework, identify potential barriers to implementation, and ensure alignment with the needs of both practitioners and service users.

Conclusions

In this study, the first core competency framework for community-based psychiatric rehabilitation practitioners in China has been developed using Delphi method. It is scientifically grounded and culturally responsive, offering a practical foundation for curriculum design, training, assessment, certification, and performance evaluation. Given workforce shortages and the absence of similar frameworks in many low- and middle-income countries, it may serve as a reference for developing contextually appropriate community-based psychiatric rehabilitation competency frameworks in other settings. As the framework developed in this study is a preliminary, expert-derived one, further empirical validation will be required before its application in certification or formal performance assessment.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

CBPR

Community-based psychiatric rehabilitation

LMICs

Low- and middle-income countries

Cr

Authority coefficient

Cs

Familiarity coefficient

Ca

Judgement coefficient

Author contributions

HY, KL, and WZ conceptualized the study. HY, HD, and ZL conducted the rapid review. HY and KL drafted the framework for community-based psychiatric rehabilitation practitioners in China, with support from ZL, HD, YS, and ZH. All authors contributed to the revision of the draft framework. HY and WZ identified and contacted the consulting experts who participated in the Delphi survey. HY collected the responses from the consulting experts. HY, ZH, and ZL performed the data analysis. ZL and ZH drafted the first version of the manuscript which was subsequently edited by all the other authors. YX supervised the study. All authors approved the final manuscript and accept responsibility for the decision to submit for publication.

Funding

The study is funded by the China Medical Board (No. 22–480) and the National Social Science Fund of China (No. 22CSH085). HY is supported by the Shanghai “Rising Stars of Medical Talent” Youth Development Program for Youth Medical Talents - Specialist Program (No. 2024-70). WZ is supported by the Liberal Arts Youth Talent Cultivation Program of Shanghai Jiao Tong University (No. 2023QN038); the Key Project of the Biomedical Engineering Cross Research Fund of Shanghai Jiao Tong University for the year 2024 “Medical-Engineering Cross Research”(No. YG2024ZD24); the 2024 Shanghai “Science and Technology Innovation Action Plan” Medical Innovation Research Project, Science and Technology Commission of Shanghai Municipality (No. 24Y22800501 and 24Y22800503); and Fudan University-Minhang District Health Consortium Collaborative Research Project (NO.2025FM03).

Data availability

The de-identified data are available on reasonable request to the corresponding authors.

Declarations

Ethics approval and consent to participate

This study involved a Delphi consensus process with expert participants. Ethical review and approval were waived by the Ethics Committee of Shanghai Mental Health Center, Shanghai Jiao Tong University, as the study was considered minimal risk. Specifically, the study involved anonymous surveys of expert opinion, with no intervention, no collection of sensitive personal or health-related data, and no foreseeable risk to participants. Participation in the Delphi survey was voluntary. All participants were provided with information about the survey and gave informed consent prior to participation. The anonymity and confidentiality of participants were maintained throughout the study. The study was conducted in accordance with the principles of the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.